Pancreatoduodenectomy (PD) is the treatment of choice for operable malignant tumors of the lower common bile duct, the duodenum, the ampulla of Vater and the periampullary region of the head of the pancreas.
Since laparoscopic PD was described to be feasible in the ‘90s, data from observational studies has suggested that this technique is superior to open PD regarding postoperative morbidity and hospital stay, as well as intraoperative blood loss, resulting in a shortened time to adjuvant treatment. Randomized ongoing trials might assess this superiority in the future. Nevertheless, this procedure remains a challenging technique, especially due to the surgical expertise required for biliary and pancreatic reconstruction. Therefore it should be performed in high-volume centers.
In this video we focus on the laparoscopic pancreatojejunostomy technique, one of the most challenging steps in minimally invasive PD.
We present the case of a 65-year-old woman, with a history of cholecistectomy, mild COPD and a smoker. She presented in the outpatient clinic with anemia and a toxic syndrome with a 14 kg weight loss. The upper endoscopy showed a tumor in the second portion of the duodenum, opposite to the papilla. The biopsy was positive for infiltrating adenocarcinoma and the CT scan showed no distant metastases in thorax or abdomen. She was diagnosed with an operable adenocarcinoma of the second duodenal portion and was proposed for laparoscopic surgical treatment. A laparoscopic PD was carried out, and the specimen was extracted through an infraumbilical mini laparotomy.
Pancreatic reconstructive procedure:
Pancreatic reconstruction is the first step in the reconstructive phase according to Child’s method. After transecting the pancreas with the Thunderbeat instrument, a non-dilated pancreatic duct is encountered, measuring less than 3mm in diameter. The jejunum, transected 10cm below the ligament of Treitz with an EndoGIA, is brought retrocolically near the pancreatic remnant.
A two layer end-to-side pancreaticojejunostomy with a small multiperforated stent is then performed. The posterior outer row consists of a running 3-0 prolene suture approximating full-thickness pancreatic tissue to seromuscular jejunum tissue. A sero-mucosal wound is made on the jejunum, in the portion closest to the pancreatic duct. The posterior row of the pancreaticojejunal duct-to-mucosa anastomosis is created, consisting of interrupted 6-0 prolene sutures. A multiperforated catheter is placed through the pancreatic duct and the jejunum, and fastened with the sutures at the ends of the posterior inner row. The anterior row of the duct-to-mucosa anastomosis is the next step and is created using the same technique. The remaining anterior outer layer is made using a running 3-0 prolene suture, completing the procedure. At the end of the surgery a drain is positioned close to the pancreatic anastomosis.
Operative time for pancreatic laparoscopic reconstruction was 52 minutes. The rest of the laparoscopic PD was carried out with no intraoperative complications. The patient underwent an uneventful post-operative period, with no pancreatic fistula, and was discharged on the 5th post-operative day.